WASHINGTON (AP) — For Gov. Rick Perry, saying “no” to the federal health care law could also mean turning away up to 1.3 million Texans, nearly half the uninsured people who could be newly eligible for coverage in his state.

Gov. Chris Christie not only would be saying “no” to President Barack Obama, but to as many as 245,000 uninsured New Jersey residents as well.

The Supreme Court’s recent ruling gave governors new flexibility to reject what some Republicans deride as “Obamacare.” But there’s a downside, too.

States that reject the law’s Medicaid expansion risk leaving behind many of their low-income uninsured residents in a coverage gap already being called the new “doughnut hole” — a reference to a Medicare gap faced by seniors.

How Will States Respond to the Supreme Court’s Decision Regarding the Medicaid Expansion?

The Supreme Court’s decision has the effect of allowing states to choose whether or not to expand eligibility for coverage under their Medicaid program pursuant to the ACA. Under that law as enacted but prior to the Court’s ruling, the Medicaid expansion appeared to be mandatory for states that wanted to continue receiving federal matching funds for any part of their Medicaid program. Hence, CBO and JCT’s previous estimates reflected the expectation that every state would expand eligibility for coverage under its Medicaid program as specified in the ACA. As a result of the Court’s decision, CBO and JCT now anticipate that some states will not expand their programs at all or will not expand coverage to the full extent authorized by the ACA. CBO and JCT also expect that some states will eventually undertake expansions but will not do so by 2014 as specified in the ACA.

Why are the Projected Medicaid and CHIP Savings Stemming from the Supreme Court’s Decision Greater than the Projected Additional Costs of Subsidies Provided through the Exchanges?

Federal spending over the 2012–2022 period for Medicaid and CHIP is now projected to be $289 billion less than previously expected, whereas the estimated costs of tax credits and other subsidies for the purchase of health insurance through the exchanges (and related spending) have risen by $210 billion. Small changes in other components of the budget estimates account for the remaining $5 billion of the difference.

The key factors leading to that result are as follows:

Only a portion of the people who will not be eligible for Medicaid as a result of the Court’s decision will be eligible for subsidies through the exchanges. According to CBO and JCT’s estimates, roughly two-thirds of the people previously estimated to become eligible for Medicaid as a result of the ACA will have income too low to qualify for exchange subsidies, and roughly one-third will have income high enough to be eligible for exchange subsidies. In addition, those who become eligible for subsidies will have to pay a portion of the exchange premium themselves, which will affect their decisions about whether to enroll in the exchanges.

For the average person who does not enroll in Medicaid as a result of the Court’s decision and becomes uninsured, federal spending will decline by roughly an estimated $6,000 in 2022.

For the average person who does not enroll in Medicaid as a result of the Court’s decision and enrolls in an exchange instead, estimated federal spending will rise by roughly $3,000 in 2022—the difference between estimated additional exchange subsidies of about $9,000 and estimated Medicaid savings of roughly $6,000.

With about 6 million fewer people being covered by Medicaid but only about 3 million more people receiving subsidies through the exchanges and about 3 million more people being uninsured, and because the average savings for each person who becomes uninsured are greater than the average additional costs for each person who receives exchange subsidies, the projected decrease in total federal spending on Medicaid is larger than the anticipated increase in total exchange subsidies.

Why Are These Estimates Uncertain?

Projections of the budgetary impact of H.R. 6079 are quite uncertain because they are based, in large part, on projections of the effects of the ACA, which are themselves highly uncertain. Assessing the effects of making broad changes in the nation’s health care and health insurance systems requires estimates of a broad array of technical, behavioral, and economic factors. Separating the incremental effects of the provisions in the ACA that affect spending for ongoing programs and revenue streams becomes more uncertain as the time since enactment grows. The recent Supreme Court decision that essentially made the expansion of the Medicaid program a state option has also increased the uncertainty of the estimates. However, CBO and JCT, in consultation with outside experts, have devoted a great deal of care and effort to the analysis of health care legislation in the past few years, and the agencies have strived to develop estimates that are in the middle of the distribution of possible outcomes.

If you live in one of the states with one of these governors, and you were hoping to utilize ACA, “forget about it”, you are screwed! If states refuse to expand Medicaid, there’s no other provision in the Affordable Care Act to cover the very poor.

Some health care experts said it was unthinkable that state leaders would really opt out, since the vast majority of the cost is covered by the federal government — taxes their citizens will pay, regardless of whether the state opts in or out. For the first two years, the federal government pays for 100 percent of the expansion. Starting in 2017, the states start chipping in, but they will never contribute more than 10 percent of the cost.

“A governor would be walking away from millions, in some cases billions of federal dollars,” Tim Jost, a consumer advocate and professor of health law at Washington and Lee University, told CBSNews.com.

Quote from an ACA opponent, “Well maybe it sucks to you but I have better things to do with my money than supporting you. If a hundred plus million people that work and pay taxes can solve their problems, those folks should solve their own. Besides in reality most able bodied people on entitlements do work, off the books.”

I sincerely hope this commenter stays healthy the rest of his life, always has a job and never grows old …

Just this CNN/Tea Party debate alone predviod those of us that follow policy a basket of lies and misinformation to correct. What I still find amazing is in the last week’s debate the Republican audience joyful reaction and applause to Rick Perry’s proclivity to grant executions and in this debate the Republican audience insensitive and immoral behavior towards the uninsured.